Armengol et al., J Spine Neurosurg 2014, 3:4 http://dx.doi.org/10.4172/2325-9701.1000149
Journal of Spine & Neurosurgery
Case Report
a SciTechnol journal
Neuroendoscopic Treatment of Intracranial Tuberculoma: Case Report Roser Garcia-Armengol1*, Marta Brell2, Javier Ibañez2, Pilar Teixidor1 and Jordi Rimbau1
Abstract Background: Intracranial tuberculoma rarely are seen in industrialized countries and represent only a small part of all intracranial space-occupying lesions. In most cases, conservative therapy provides good results. When treatment is not effective or lesion enlarged, surgery is recommended. Role of surgery in patients with intracranial tuberculomas is not yet established. This report describes a case of symptomatic intracranial tuberculoma and minimally invasive surgical option of treatment with ventricular neuroendoscopic aspiration. Case Report: We report the case of a 21-year-old man who presented with a 2-months history of meningeal tuberculosis. After two months of well-tolerated antituberculous treatment, patient presented mild visual lost and headache. Neurological examination reveals bilateral papilledema, and gait ataxia. MRI identified perimesencephalic tuberculoma, situated into pineal recess that caused an aqueductal stenosis and obstructive hydrocephalus. Hydrocephalus was well treated with a third endoscopic ventriculostomy, and optical symptoms improve after that. Two weeks later patient presented a progressive hearing loss, diplopia and bilateral palpebral ptosis. MRI showed perimesencepahlic tuberculoma enlargement with little satellite neighbor tuberculoma. Ventricular size not shows any changes, and transependymal absorption of CSF is not evident. Results: We surgically treat this large perimesencephalic tuberculoma with ventricular endoscopy guided with neuronavigation and aspirated granuloma content. After undergoing 6 months of treatment, the patient’s follow-up CT and MRI reveal a decrease in tuberculoma volume. Conclusion: Neuroendoscopy can be us to treat cerebral tuberculous granulomas if size, location, and granuloma content, allow use of this technique, with carefully aspiration of cesium for avoid tuberculous yatrogenic meningitis.
Keywords Intracranial tuberculoma; Neuroendoscopy; Third endoscopy
Abbreviations MRI: Magnetic Resonance Imaging; CSF: Cerebrospinal Fluid; CT: Computed Tomography; ICP: Intracranial Pressure; HIV: Human Inmudeficency Virus; INO: Internuclear Ophthalmoplegia; MLF: Medial Longitudinal Fasciculus Fibers *Corresponding author: R Garcia-Armengol, Neurosurgery Department, University Hospital Germans Trias i Pujol, Barcelona, Spain, Tel: +34.699.22.02.12; Fax: +34.497.89.11; E-mail:
[email protected] Received: February 24, 2014 Accepted: April 21, 2014 Published: April 25, 2014
International Publisher of Science, Technology and Medicine
Introduction Intracranial tuberculoma is a common entity in developing countries [1], however in industrialized countries, intracranial tuberculoma represent only a small part of all intracranial spaceoccupying lesions. We report one rare case of symptomatic tuberculoma situated into pineal recess that developed and increased during treatment of Central Nervous System Tuberculosis in healthy host, immigrated from developing country, treated with ventricular neuroendoscopic aspiration guided with neuronavigation with good clinical, neurological, and radiological results with this treatment.
Material and Methods This 21-year-old right-handed man grew up in Bolivia (South America) and immigrated to Spain two months ago. Patient initially presented to another hospital with signs and symptoms of pulmonary tuberculosis, ileitis and after, he suffered a rapid deterioration in his neurological status and was comatose. CSF culture shows meningeal tuberculosis. His medical history was otherwise unremarkable, and patient denied any exposure to infected individuals, or any history of substance abuse. He was living with his family, none of whom had tuberculosis. Serological examination for HIV was negative. Quantitative C-reactive protein and chest x-ray film was normal He was well treated with tuberculostatic therapy, and neurological symptoms improve after four months of treatment. Two month after presented signs and symptoms of ventricular enlargement and increase of ICP with bilateral papilledema. MRI identified a large perimesencephalic tuberculous granuloma with homogeneous hypointense signals on T1-weighted image, hyperintense signals on T2 -weighted image, and ring enhancement T1-weighted sequences, who caused an aqueductal stenosis and acute hydrocephalus with transependymal absorption of CSF. Initial he underwent a third ventriculostomy with right frontal approach. A follow-up examination revealed marked improvement in gait and bilateral papilledema. After third endoscopic ventriculostomy, ventricular MRI shows a reduction in ventricular size, and demonstrated fenestration of premmamillary membrane. He was discharged at home and instructed to continue a three-drug (isoniazid, rifampin, and ethambutol) regimen, and high dose steroid therapy for treatment M. Tuberculosis infection. Neurosurgical, ophthalmologic, and infectious disease departments followed patient on an outpatient basis. Two weeks later patient was readmitted with complaints of headache, blurred vision, bilateral ptosis, bilateral superior oblique muscle palsy, bilateral internuclear ophthalmoplegia, hearing loss, and gait ataxia. Cognition was intact and there were no signs of meningism. MRI showed perimesencepahlic tuberculoma enlargement with little satellite neighbour lesions. Ventricular size not shows any changes, and transependymal absorption of CSF is not evident (Figure 1). An elective neuroendoscopic carefully aspiration guided with neuronavigation of the largest lesion was performed (Figure 2). We avoided the exit of the cyst content to ventricle, as soon as possible. Previous endoscopic third ventriculostomy was revised
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Citation: Armengol RG, Brell M, Ibañez J, Teixidor P, Rimbau J (2014) Neuroendoscopic Treatment of Intracranial Tuberculoma: Case Report. J Spine Neurosurg 3:4
doi:http://dx.doi.org/10.4172/2325-9701.1000149 at surgery grew M. Tuberculosis. Any other microorganism grew into granuloma, and anatomopathological examination revealed caseating necrosis and Langerhans-type giant cells, but no acid-fast bacilli. His neurological deficits have slowly improved; Gait ataxia, palpebral ptosis and hearing loss have resolved; INO and fourth nerve bilateral palsy improved, but is present in moment of the discharge. Progressive neurological recovery was accompanied by satisfactory radiological tuberculoma reduction within the first 6 months of treatment.
Results
Figure 1: Magnetic resonance images (MRI) showing tuberculous granuloma hypointense signal, with ring enhancement in Gadolinium-contrast axial image of T1-weighted sequence. Before ventriculostomy, and two weeks later. Preoperative, postoperative, and 6 months later magnetic resonance, reveal a decrease in tuberculoma size.
Recent epidemiological studies have documented a rise in the number of reported cases of systemic tuberculosis. Approximately 1.7 billion individuals worldwide are infected with M. tuberculosis [2]. Intracranial tuberculomas rarely are seen in industrialized countries [3]. Tuberculoma usually results from the hematogenous seeding of the tubercle bacilli to the leptomeninges and brain parenchyma, resulting in the formation of tubercles. Brainstem tuberculoma or adjacent at this location, in the other hand, remains an uncommon clinical entity. Only 4% of intracranial tuberculomas are situated within the brain stem [4]. Eye movement disorders that have been described in association with brainstem tuberculomas include palsies of third and six cranial nerves, vertical gaze dysfunctions, convergence nystagmus and internuclear ophthalmoplegia [4,5]. Although in our case, tuberculoma was in the pineal recess, we believe that the tuberculoma enlargement caused symptoms by compression of the midbrain. The ocular abnormal motility in our patient was consisted in four and seventh bilateral cranial nerves palsy and internuclear bilateral ophthalmoplegia. We argued that Internuclear bilateral ophthalmoplegia was caused by tuberculoma in the dorsal pontine tegmentum, which interrupted function of internuclear MLF fibers and seven cranial nerve, was affected partially with Muller muscle palsy for compression of bilaterally facial colliculus. Also we suggest that fourth cranial nerve is affected by compression into mesencephalic nuclei, with is situated immediately below to the inferior colliculus. Our patient’s MRI demonstrated a compression of fourth ventricle flour, and mesencephalic tectum (Figure 2). In our case hearing function was probably affected by inferior colliculus compression.
Figure 2: Intraoperative photographs of neuroendoscopy showing well vascularized cyst wall. Intraoperative photographs of neuroendoscopy showing cesium of tuberculous granuloma.
testing its permeability. We perform a granuloma biopsy. After surgery high dose of corticosteroids was applicated. After 6 weeks of incubation, granuloma content cultures obtained
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Adjunctive therapy with steroids appears to diminish neurological symptoms and may improve outcome in patients with tuberculoma [5,6]. Corticosteroids were administered during the first month of chemotherapy to reduce and control the perilesional edema. Paradoxical enlargement or development of intracranial tuberculomas during therapy: has been previously reported as our case [5,7]. The risk of such a paradoxical response appears to be the highest within the first 3 months of therapy and is thought to represent an interaction between the host’s immune response and the direct effects of mycobacterium products [6-8] . Anyway, the use of adjunctive steroids to suppress a paradoxical response is not proven. Although drug regimens are the mainstay of therapy, surgical intervention has its role in the management of intracranial tuberculosis [1]. Tuberculoma may be diagnostically challenging on conventional MRI because of its similar appearance to other rim enhancing lesions (such as bacterial abscesses and central tumor necrosis). Several authors consider mandatory to obtain a histological diagnosis before starting therapy [1,6]. • Page 2 of 3 •
Citation: Armengol RG, Brell M, Ibañez J, Teixidor P, Rimbau J (2014) Neuroendoscopic Treatment of Intracranial Tuberculoma: Case Report. J Spine Neurosurg 3:4
doi:http://dx.doi.org/10.4172/2325-9701.1000149 Performing a biopsy on a suspected tuberculoma continues to be debated. CT guided sterotactic biopsy is a safer option to diagnose brain stem tuberculomas or deep tuberculomas by some authors with less morbidity than open procedures [5]. Nevertheless, other reports suggests that brain biopsy harbors certain risks of deadly complications such bleeding or meningeal spread of infection, and it may be inappropriate to diagnose tuberculoma that is potentially a benign disease [1,3,9]. However recent reviews show that conducting stereotactic or open biopsies may hasten diagnosis, thus allowing more expeditious treatment [1] , and in some cases, surgical excision in large lesions with mass effect, not only helped to establish the histological diagnosis, but also helped to resolve the compressive symptoms, like our patient. Interestingly we report in this paper a case of perimesencephalic tuberculoma treated with ventricular neuroendoscopic neuronavigation. Tuberculomas brain abscess can be difficult to differentiate from other lesions like, and we consider histopathological analysis necessary by his management. Ventricular neuroendoscopic neuronavigation, undertaken with caution, is a good alternative mode of diagnoses and treatment, in large deep tuberculoma. Although it has been described the use of the neuroendoscope in hydrocephalus secondary to tuberculous infection could be technically difficult, especially in acute stage of disease due to an inflamed, thick and opaque third ventricle floor and, intraoperative neural injury, such as thalamic, forniceal, hypothalamic and midbrain injuries, and hemorrhages inluding fatal hemorrhage are also observed [10] , we believe that neuroendoscopy can be used to treat cerebral tuberculous granulomas if size, location, and granuloma content allow use of this technique, with carefully aspiration of tuberculoma for avoid tuberculous iatrogenic meningitis.
Acknowledgment The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
References 1. Bouchama A, al-Kawi MZ, Kanaan I, Coates R, Jallu A, et al. (1991) Brain biopsy in tuberculoma: the risks and benefits. Neurosurgery 28: 405-409. 2. Kochi A (1991) The global tuberculosis situation and the new control strategy of the World Health Organization. Tubercle 72: 1-6. 3. Knauer-Fischer S, Schaper J, Janssen HT, Ratjen F (1999) Tuberculoma of the pons. Pediatr Neurol 20: 57-59. 4. Minagar A, Schatz NJ, Glaser JS (2000) Case report: one-and-a-halfsyndrome and tuberculosis of the pons in a patient with AIDS. AIDS Patient Care STDS 14: 461-464. 5. Rajshekhar V, Chandy MJ (1997) Tuberculomas presenting as isolated intrinsic brain stem masses. Br J Neurosurg 11: 127-133. 6. Poonnoose SI, Rajshekhar V (2003) Rate of resolution of histologically verified intracranial tuberculomas. Neurosurgery 53: 873-878. 7. Chambers ST, Hendrickse WA, Record C, Rudge P, Smith H (1984) Paradoxical expansion of intracranial tuberculomas during chemotherapy. Lancet 2: 181-184. 8. Afghani B, Lieberman JM (1994) Paradoxical enlargement or development of intracranial tuberculomas during therapy: case report and review. Clin Infect Dis 19: 1092-1099. 9. Kumar R, Jain R, Kaur A, Chhabra DK (2000) Brain stem tuberculosis in children. Br J Neurosurg 14: 356-361. 10. Chugh A, Husain M, Gupta RK, Ojha BK, Chandra A, et al. (2009) Surgical outcome of tuberculous meningitis hydrocephalus treated by endoscopic third ventriculostomy: Prognostic factors and postoperative neuroimaging for functional assessment of ventriculostomy. J Neurosurg Pediatr 3: 371-377.
Author Affiliation
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Neurosurgery Department, University Hospital Germans Trias i Pujol, Barcelona, Spain
1
Neurosurgery Department, University Hospital Son Espases, Palma de Mallorca, Spain
2
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